Provider Demographics
NPI:1689047946
Name:BANDA, JUAN PABLO
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:BANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W METROPOLITAN DR # 405
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3504
Mailing Address - Country:US
Mailing Address - Phone:714-645-8000
Mailing Address - Fax:714-954-2985
Practice Address - Street 1:4000 W METROPOLITAN DR # 405
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:714-645-8000
Practice Address - Fax:714-954-2985
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131602106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist